Healthcare Provider Details

I. General information

NPI: 1588525117
Provider Name (Legal Business Name): EMMARS PROVIDENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4054 51ST WAY S
FARGO ND
58104-6080
US

IV. Provider business mailing address

4054 51ST WAY S
FARGO ND
58104-6080
US

V. Phone/Fax

Practice location:
  • Phone: 240-853-8325
  • Fax:
Mailing address:
  • Phone: 240-853-8325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State

VIII. Authorized Official

Name: MARIE DORE
Title or Position: CEO
Credential:
Phone: 240-853-8325